Child Survey: Ages 1 - 18 Months - OhioGuidestone Research Portal

Electronic Agreement *

By checking this box, I agree to use electronic records and electronic signatures.

Access Code *

Date *

Person Completing Form *

Mom
Dad
Other

If other, please explain *

Form Number *

If other, please explain *

Questionnaire for Babies 1-18 Months Old

Please read each statement carefully and answer for your child that is participating in the study. If you have more than one child participating, please complete one for each child. There are no right or wrong answers!

Select the answer that best fits: Never, Rarely, Occasionally, Frequently, Very Frequently

During the past 4 weeks, how often did your child:

Try to do new things? *

Respond when spoken to? *

Imitate actions of others? *

Enjoy interacting with others? *

Keep trying when unsuccessful? *

Enjoy being cuddled? *

Show interest in what others were doing? *

Show affection for a familiar adult? *

Notice changes in surroundings? *

Seek comfort from familiar adults? *

Adjust her/his energy level to the type of play? *

Act in a good mood? *

Act happy when praised? *

Make eye contact with others? *

Explore surroundings? *

Calm down with help from a familiar adult? *

Express her/his dislikes? *

Smile back at a familiar adult? *

Reach for a familiar adult? *

Respond to her/his name? *

Keep trying to obtain a toy? *

React to another child's cry? *

Smile at familiar adults? *

Respond positively to adult attention? *

Act happy? *

Act in a way that makes others smile or show interest? *

Easily go from one activity to another? *

Seek attention when a familiar adult was with another child? *

Look to a familiar adult when exploring her/his surroundings? *

Enjoy being around other children? *

Show pleasure when interacting with adults? *

Act happy with familiar adults? *

Accept comfort from a familiar adult? *

How was this form completed? *

In-Person
By Phone
Online
Mail-In

Child Survey: Ages 1 – 18 Months

Questionnaire for Babies 1-18 Months Old

During the past 4 weeks, how often did your child: